Provider Demographics
NPI:1578940102
Name:SPECDENT PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:SPECDENT PROFESSIONAL CORPORATION
Other - Org Name:RICHMOND AVENUE DENTAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:RASSNER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:832-930-4075
Mailing Address - Street 1:6430 RICHMOND AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77057-5917
Mailing Address - Country:US
Mailing Address - Phone:832-930-4075
Mailing Address - Fax:832-930-4079
Practice Address - Street 1:6430 RICHMOND AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77057-5917
Practice Address - Country:US
Practice Address - Phone:832-930-4075
Practice Address - Fax:832-930-4079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16793122300000X
TX274411223E0200X
TX245681223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty